Orthostatic Vital Signs (Ambulatory) - CE

ALERT

Do not check orthostatic vital signs in patients with supine hypotension, shock, or severe alteration in mental status, or in those who may have spinal, pelvic, or lower-leg injuries.^{undefined#ref4">4}

Medications that block a patient’s normal vasomotor and chronotropic response will interfere with fluid volume evaluation; however, to evaluate a patient’s reaction to a medication, obtaining orthostatic vital signs can be helpful.

Anticipate that the patient may experience dizziness and that an assistant may be necessary to help move the patient from a lying to a standing position. Do not leave the patient alone during this procedure.

OVERVIEW

Orthostatic vital signs are performed with the patient in different positions. The measurement of orthostatic vital signs is sometimes referred to as postural vital signs or the tilt test. This procedure is used for noninvasive evaluation of fluid loss from conditions such as vomiting, diarrhea, diaphoresis, bleeding, abdominal pain, and blunt abdominal or chest trauma. It can also be used to evaluate cerebral hypotension, unexplained syncope, weakness or dizziness, autonomic dysfunction, systemic hypotension, and response to a change in position in the older adult or ill patient.⁶ Orthostatic hypotension is impacted by increasing age, diagnosis of hypertension, multiple hypertensive medications, as well as polypharmacy.¹

The value of orthostatic vital signs is disputed because there is no universal method on how to perform them or what blood pressure and heart rate changes constitute positive orthostatics. Orthostatic vital signs alone lack the sensitivity to detect volume losses of less than 1000 ml reliably.² Therefore, the vital signs should be interpreted in the context of the patient’s other symptoms, such as dizziness, lightheadedness, fatigue, visual dimming, and shoulder pain.³ These symptoms can be aggravated by hot environments and in patients who tend to stand still without frequently changing position. Signs and symptoms of orthostatic changes are typically not present when the patient is supine but mostly materialize while standing and can be quickly resolved by sitting or lying down.³

SUPPLIES

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EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Teach the patient the signs and symptoms of orthostatic hypotension (e.g., dizziness, lightheadedness, fatigue) and provide instructions on when to seek additional care.
• Encourage the patient to report feelings of dizziness or instability when changing positions during testing. If the patient feels dizzy or unstable, the test should be terminated, and the patient assisted to lie down before falling.
• Educate the patient with postural symptoms about the importance of sitting for several minutes before getting out of bed and standing up slowly after sitting for an extended time.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Explain the procedure and ensure that the patient agrees to treatment.
5. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
6. Determine the patient’s medication history. Certain medications can predispose a patient to orthostatic hypotension in the absence of hypovolemia:⁴
   1. Sympatholytic drugs
   2. Diuretics
   3. Nitrates
   4. Opioids
   5. Antihistamines
   6. Psychotropic agents
   7. Barbiturates
   8. Antihypertensives
   9. Anticholinergics
7. Have the patient lie in a supine position for 5 to 10 minutes before taking the initial measurements.²

   Prevent unreliable results by avoiding invasive or painful procedures during the measurement of orthostatic vital signs.

8. Measure blood pressure and heart rate after the patient has been in a supine position for 5 to 10 minutes.² Use the appropriate-size blood pressure cuff. The correct cuff size is determined by arm circumference (Table 1).⁵
9. Assist the patient as needed with moving from a supine to a standing position. If the patient is unable to stand for a blood pressure measurement, try either the high-Fowler or the sitting position, although the results may be less credible. A supine-to-standing measurement is more accurate than a supine-to-sitting measurement.²
10. Question the patient about weakness, dizziness, or visual dimming associated with a change of position. Observe for pallor or diaphoresis. These symptoms are as important as the measurement of vital signs.²

    Terminate the measurement if the patient becomes extremely dizzy and needs to lie down or experiences syncope.

11. Take the standing or sitting blood pressure (in the same arm as the initial readings) and determine the heart rate at 1 and 3 minutes after the position change.² Support the patient’s arm at heart level when obtaining blood pressure to prevent an inaccurate measurement.⁵ When measuring orthostatic vital signs, one or more of these findings may indicate intravascular volume loss in adults:²
    1. Decrease in systolic blood pressure of 20 mm Hg or more
    2. Decrease in diastolic blood pressure of 10 mm Hg or more
    3. Increase in heart rate of 20 beats per minute or more
12. Assist the patient as needed with returning to a supine or sitting position.
13. Monitor for the resolution of symptoms such as dizziness, visual changes, or hypotension if any occurred during the measurement of orthostatic vital signs.
14. Discard supplies, remove PPE, and perform hand hygiene.
15. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Accurate and safe measurement of pulse and blood pressure with position changes

UNEXPECTED OUTCOMES

• Weakness, dizziness, syncope, and falls, which may be indicative of volume depletion
• Paradoxical bradycardia, which may be observed in hypovolemic patients who have rapid and massive bleeding and may be interpreted as orthostasis⁴

DOCUMENTATION

• Vital signs measurements, including position in which measurements were taken (i.e., with patient lying down, in high-Fowler position, sitting, or standing), right or left arm, as well as patient reports of dizziness or visual changes
• Unexpected outcomes and related interventions
• Education
• Evaluation findings communicated to the clinical team leader per the organization’s practice

PEDIATRIC CONSIDERATIONS

• The usefulness of orthostatic vital signs in pediatric patients is not clear.² Postural near-syncope or an increase in heart rate of 25 beats per minute or more may be a predictor of dehydration in pediatric patients.⁴
• Determining dehydration in pediatric patients should be based on capillary refill and clinical evaluation, as well as a comparison of the patient’s weight before and after the illness.
• Asking the family about the number of wet diapers changed per day helps to determine how often the patient is urinating in comparison to normal.

OLDER ADULT CONSIDERATIONS

• Patients with nondemand pacemakers or those taking beta blocker medications may not have significant changes in heart rate.
• Blood pressure should be routinely taken with the patient in the standing position to evaluate for orthostatic hypotension.
• Older adult patients should be educated on the importance of sitting for several minutes before getting out of bed and standing up slowly after sitting for an extended time.

REFERENCES

1. Elliott, W.J., Peixoto, A.J., Bakris, G.L. (2020). Chapter 46: Primary and secondary hypertension. In A. Yu and others (Eds.), Brenner and Rector’s: The kidney (11th ed., pp. 1536-1579). Philadelphia: Elsevier.
2. Emergency Nurses Association (ENA). (2018). Clinical practice guideline: Orthostatic vital signs. Retrieved May 17, 2022, from https://www.ena.org/ (Level VII)
3. Kamali, F. (2022). Chapter 18: Hypotension and syncope. In M. Maleki and others (Eds.), Practical cardiology: Principles and approaches (2nd ed., pp. 329-340). Philadelphia: Elsevier.
4. McGrath, J.L., Bachmann, D.J. (2019). Chapter 1: Vital signs measurement. In J.R. Roberts and others (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (7th ed., pp. 1-22). Philadelphia: Elsevier.
5. Muntner, P. and others. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. doi:10.1161/HYP.0000000000000087 (Level VII)
6. O’Riordan, S. and others. (2017). Measurement of lying and standing blood pressure in hospital. Nursing Older People, 29(8), 20-26. doi:10.7748/nop.2017.e961 (Level VII)

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports